Multicultural Background Questionnaire

Individuals with Dementia from Diverse Cultural Backgrounds: a Person-Centered Questionnaire

Please complete all the fields in the questionnaire. If you do not know a specific answer, leave it blank or mark "I don't know." The more detailed and complete your responses, the more accurate and helpful the recommendations will be in improving daily interactions and care. This questionnaire has been designed to collect detailed information about the older individual, allowing for a more personalized approach to their care. The responses provided will help generate a report with tailored suggestions and strategies based on their life history, culture, and current condition. Since many older adults are immigrants, this questionnaire aims to capture their cultural background, traditions, and past experiences, offering insights to facilitate communication and caregiving approaches that align with their personal history

Name and Last Name (Just Initials)

Date of Birth

Do they have a religion or meaningful beliefs? If so, especify

Do they have children? If so, mention quantity and for grandchildren as well

Food Preferences (mention here favourite dishes and major dislikes)

Social/Cultural background

Place of birth (country and city) – Please mention if the person has moved to any significant places throughout their life

Languages spoken (In case the person is not able to comunicate indicate what they used to speak)

Marital Status (married, widowed, single, divorced, partnered)

Do you know if they have any special cultural tradition? If so, specify

Have they immigrated? If yes, when and where did they move to and why?

Are family members present in the person's daily life? (Yes / No / Occasionally / They live far away but call frequently)

If you tick other, please specify

Occupation and Interests

What is their level of education (How many years o study and their certificates)

Are they able to read or write in any language?

Do they have HOBBIES (indicate if it is past or currently)

What they like watch on TV and listen on raio?

Occupations throughout their life

What they like to do during free time (past and current interest)

Preferences and Daily Routine

Daily Routie

What time of the day is the person the calmest and most receptive

How do they prefer to be approached? (Example: being called by their first name, direct eye contact, soft tone of voice)

Are there any familiar words or phrases in their native language that could help with communication?

What personal objects or activities bring them comfort?

Do they usually sleep well? (Yes / No, they have insomnia or wake up frequently)

How do they react to physical touch? (Enjoys it / Prefers personal space / Depends on the person)

Medical History

Please provide summary of their medical history, includind diagnosis

Medications

Cognition and Behavior (Any Physical or Cognitive Decline)

Mobility

Personal Care

Sensory

Nutrition and Hydration

Toileting and Continence

If you are unsure of your answers, you may select from the options below instead of typing. Otherwise just skip to the "Carer Details" section

Sensory background

Tick the item(s) below that best represent the person you are seeking guidance for.

Sensory background

Nutrional data - Level of drink

Thin fluids

Thick

Mobility Data

Tick the item(s) below that best represent the person you are seeking guidance for.

Physical Ability - Hands

Free movement of hands (precise- able to hold cutlery/pencils)

Raw Movements (slow/shaking or with difficulty)

Simple movements (open and close)

Rigid hands

Cognitive Abilities and Behaviors

Agitation

Able to self Initiate Tasks

Resealable patience level (waits for their turn)

Impulsive (unable to think before acts)

Knows limits (understand when it is time to stop/wait)

Wandering

Attention

Holds attention on a task for long periods (able to watch over 30 minute videos)

Holds attention on task for short periods (able to sit still for no more than 5 minutes)

Holds attention with engagement (only pays attention if someone is sitting together)

Unable to pay attention

Understanding/Follow Instructions

Associate (able to ask how the something feels like)

Need clues

No understanding at all

Tick the item(s) below that best represent the person you are seeking guidance for.

Long term Memory - Remember about the past

Remember about all their personal life details

Remember about some of their personal life details

Needs clues (able to recognize in pictures or when voiced to them details about their personal life)

Remember about cultural knowledge

Lives in the past (acts as if it was a younger age in a different time of their life)

ADL habits (able to maintain routine like eating

No active memory

Looped speech (able to remember only limited stories from the past and repeat it non stop)

Does the individual exhibit any challenging behaviors? (Check all that apply)

Perception

Correct use of objects (able to spot an object and use it properly)

Difficulty of seeing similar colours

Sensible to Lights

Need environment with objects

Can’t see

Difficulty with small objects

Measures already attempted to reduce these behaviors:

OPTIONAL: Additional Information

Carer Details

This section is about the person filling this form. We need to know your relationship with the older adult, your country of residence, and the language you speak to better assist you.

YOUR Place of birth (country and city)

YOUR Place of Residence

In which language would you like to generate this report? (If English is not your native language feel to request any other language)

What are your expectations for this report?

1/3

Please save your data before proceeding

Primordial Mente

Individuals with Dementia from Diverse Cultural Backgrounds: a Person-Centered Questionnaire

Social/Cultural background

Occupation and Interests

Preferences and Daily Routine

Medical History

Sensory background

Mobility Data

Cognitive Abilities and Behaviors

Carer Details

Primordial
Mente